Background & Aims

Guidelines recommend endoscopic surveillance of patients with Barrett’s esophagus (BE) to identify those with dysplasia (a precursor of carcinoma) or early-stage esophageal adenocarcinoma (EAC) who can be treated endoscopically. However, it is unclear whether surveillance increases survival times of patients with BE. We performed a systematic review and meta-analysis to qualitatively and quantitatively examine evidence for the association of endoscopic surveillance in patients with BE with survival and other outcomes.

Methods

We searched publication databases for studies reporting the effects of endoscopic surveillance on mortality and other EAC-related outcomes. We reviewed randomized controlled trials, case-control studies, studies comparing patients with BE who received regular surveillance with those who did not receive regular surveillance, and studies comparing outcomes of patients with surveillance-detected EAC vs symptom-detected EACs. We performed a meta-analysis of surveillance studies to generate summary estimates using a random effects model. The primary aim was to examine the association of BE surveillance on EAC-related mortality. Secondary aims were to examine the association of BE surveillance with all-cause mortality and EAC stage at time of diagnosis.

Results

A single case-control study did not show any association between surveillance and EAC-related mortality. A meta-analysis of 4 cohort studies found that lower EAC-related and all-cause mortality were associated with regular surveillance (relative risk, 0.60; 95% CI, 0.50–0.71; hazard ratio, 0.75; 95% CI, 0.59–0.94). Meta-analysis of 12 cohort studies showed lower EAC-related and all-cause mortality among patients with surveillance-detected EAC vs symptom-detected EAC (relative risk, 0.73; 95% CI, 0.57–0.94; hazard ratio, 0.59; 95% CI, 0.45–0.76). Lead- and length-time bias adjustment substantially attenuated/eliminated the observed benefits. Surveillance was associated with detection of EAC at earlier stages. A randomized trial is underway to evaluate the effects of endoscopic surveillance on mortality in patients with BE.

Conclusions

In a systematic review and meta-analysis of the effects of surveillance in patients with BE, surveillance as currently performed was associated with detection of earlier-stage EAC and may provide a small survival benefit. However, the effects of confounding biases on these estimates are not fully defined and may completely or partially explain the observed differences between surveyed and unsurveyed patients.

中文翻译：

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内镜监测对巴雷特食管患者的影响：系统评价和荟萃分析

背景与目标

指南建议对Barrett食道（BE）的患者进行内窥镜检查，以鉴别出不典型增生（癌的前体）或早期食道腺癌（EAC）的患者，可以通过内窥镜治疗。但是，尚不清楚监视是否会增加BE患者的生存时间。我们进行了系统的回顾和荟萃分析，以定性和定量地检查BE患者生存率和其他结局的内镜监测证据。

方法

我们搜索了出版物数据库，以研究报告内窥镜监测对死亡率和其他EAC相关结局的影响。我们回顾了随机对照试验，病例对照研究，比较接受定期监测的BE患者和未接受定期监测的BE患者的研究，以及比较接受监测的EAC与有症状的EAC的患者结局的研究。我们对监测研究进行了荟萃分析，以使用随机效应模型生成汇总估算。主要目的是研究BE监测与EAC相关死亡率的相关性。次要目的是在诊断时检查BE监测与全因死亡率和EAC分期的相关性。

结果

一项病例对照研究未显示监测与EAC相关死亡率之间有任何关联。对4项队列研究的荟萃分析发现，较低的EAC相关死亡率和全因死亡率与定期监测相关（相对风险，0.60； 95％CI，0.50-0.71；危险比，0.75； 95％CI，0.59-0.94 ）。对12项队列研究的荟萃分析显示，在监测发现的EAC与症状发现的EAC的患者中，与EAC相关和全因死亡率较低（相对危险度，0.73； 95％CI，0.57-0.94；危险比，0.59； 95％ CI，0.45-0.76）。提前期和工期偏差调整显着减弱/消除了所观察到的好处。监视与早期阶段的EAC检测有关。正在进行一项随机试验，以评估内窥镜监测对BE患者死亡率的影响。

结论

在对BE患者进行监视的效果的系统评价和荟萃分析中，当前进行的监视与早期EAC的检测有关，可能会带来较小的生存获益。但是，混杂偏差对这些估计的影响尚未完全定义，可能会完全或部分解释所调查和未调查患者之间观察到的差异。